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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stocktou, Calif. IOERI fir 7ZP C'oA1TP1W7-0ie <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lrf <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued /0- �d,?S- <br /> (Complete In Triplicate) <br /> Application is ,hereby made- to the San. Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application- is made in compliance with San Joaquin <br /> County,Ordinance No. 1862 acid the Rules and -Regulations of' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �C 3r�� �C.�� ,�sc ,cD/E/ CENSUS TRACT <br /> Owner's-Name o 7 M Q SS Phone S 4�q-go $S <br /> Address 3®s R9. - . �F /� Cityz��� <br /> Contractor's Name i ��3neo 7-,E 14/4 - License [[ [ l� Phone��� <br /> s=-TYPEOF=WORK (Check):- NEW-WELL DEEPEN---/ /—'RECONDITIONV / ` DESTRUCTI4N _ R <br /> PUMP INSTALLATION 0 PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT - OTHER <br /> INTENDED USE 1TYPE F WELL CONSTRUCTION SPECIFICATIONS ( , <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �1 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor7CZ6e,,C�G ort Z�ll1f��7 <br /> Type of Pump eB A/E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done-- -+ <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> . Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL REP T of the we and notify them before putting the well in use. The above <br /> informat n is tr to &thbes of my knowledge and belief. <br /> SIGNED <br /> TITLE CTl4f/ti GGi <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^" <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHAS III/ INSPECTION <br /> L INSPECTION BY �' ATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M ti <br />